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BACKVNATER PREVENTI�JfV PROGRAtN <br />� INVOICE C05T' E3RFAi�C�OWiV <br />Please use this Invoice Cost BreaHdorm 2s a template for invaices submitted as part uf the Backwater <br />Prevention Device rebate program. Either this form or your own invoice form v✓ith the following line items can <br />be submitted. This allo�vs you to invoir.e your client accordiny to your existing billing template while allowina <br />city st�ff to identify Itiow Costs eligible ior the Backw�ter Prevention Device Rebate were accrued. <br />Unlylahor and materials dlrecf;y related to the installation and function of a backwafer prevention <br />device are ellgible for Ci[y rehate and therefore should he included an the upper half of this form. <br />Additional costs may e dded to bottom of the (orm. <br />a�s �� 5��,� ,��iss g -2 � sl <br />Busiiiess Name: dl; � _ License Number. <br />Business Mailing Address: <br />���3 a3ro�y 5�-s.w, �'�f���s �4- �g�a6 <br />/� Cit State I Zip <br />Phone:�l�� �IGs - �(l�t� Email:�— i�au,� ' "���'dZ'a�[.C�M <br />�Cevised 3/03/2014 <br />:,,,,}` � � � ��:�_. � � <br />„"±t:rk�L.i"'�2�.'�=�'r��.�E'itl�!�,-. .�lco:',, _- ;}�,. _' �`�N'�'x.,''«��e.�"'.W,_� , `� �__ ........ <br />